title: Prehospital triage to primary stroke centers and rate of stroke thrombolysis.
abstract: OBJECTIVE
  Implementation of prehospital stroke triage is a public policy intervention that can have an immediate impact on acute stroke care in a region. OBJECTIVE To evaluate the impact that a citywide policy recommending prehospital triage of patients with suspected stroke to the nearest primary stroke center had on intravenous tissue plasminogen activator (tPA) use in Chicago, Illinois.
  
  
  METHODS
  Retrospective multicenter cohort study from September 1, 2010, to August 31, 2011 (6 months before and after intervention that began March 1, 2011).
  
  
  METHODS
  Ten primary stroke center hospitals in Chicago.
  
  
  METHODS
  All admitted patients with stroke and transient ischemic attack. INTERVENTION Prehospital triage policy of patients with stroke to primary stroke centers.
  
  
  METHODS
  Intravenous tPA use (measured as a fraction of patients with ischemic strokes arriving through the emergency department). RESULTS There were 1075 stroke and transient ischemic attack admissions in the pretriage period and 1172 in the posttriage period. Patient demographic characteristics including age, sex, and risk factors were similar between the 2 periods (mean age, 65 years; 53% female). Compared with the pretriage period, use of emergency medical services increased from 30.2% to 38.1% (P < .001) and emergency medical services prenotification increased from 65.5% to 76.5% (P = .001) after implementation. Rates of intravenous tPA use were 3.8% and 10.1% (P < .001) and onset-to-treatment times decreased from 171.7 to 145.7 minutes (P = .03) in the pretriage and posttriage periods, respectively. Stroke unit admission, symptomatic intracranial hemorrhage rates, and in-hospital mortality were not significantly different between periods. Adjusting for mode of arrival, prehospital notification, and onset-to-arrival time, the posttriage period was independently associated with increased tPA use for patients with ischemic stroke presenting through the emergency department (adjusted odds ratio = 2.21; 95% CI, 1.34-3.64).
  
  
  CONCLUSIONS
  Implementation of a prehospital stroke triage policy in Chicago resulted in significant improvements in emergency medical services use and prenotification and more than doubled intravenous tPA use at primary stroke centers.
authors.affiliation: Department of Neurology, Northwestern University, Chicago, Illinois.
authors.forename: Shyam
authors.initials: S
authors.lastname: Prabhakaran
authors.forename: Kathleen
authors.initials: K
authors.lastname: O'Neill
authors.forename: Leslie
authors.initials: L
authors.lastname: Stein-Spencer
authors.forename: James
authors.initials: J
authors.lastname: Walter
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Alberts
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002641:Chicago; D015331:Cohort Studies; D004636:Emergency Service, Hospital; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006297:Health Services Accessibility; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000517:prevention & control; D015912:Thrombolytic Therapy / Q000379:methods; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D014218:Triage
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator